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Indian J Community Med
Indian J Community Med
IJCM
Indian J Community Med
Indian Journal of Community Medicine: Official Publication of Indian Association of Preventive & Social Medicine
0970-0218
1998-3581
Wolters Kluwer - Medknow India

IJCM-49-610
10.4103/ijcm.ijcm_58_23
Original Article
Qualitative Study to Identify Strengths, Weakness, Opportunities, and Challenges of Family Adoption Programs among Students
Reshmi Panchasheela S
Lunagariya Ruchita
Patel Hiren 1
Patel Nikhil 2
Chauhan Dixit 2
Patel Ravi 2
Department of Community Medicine, Sal Institute of Medical Sciences, Ahmedabad, Gujarat, India
1 Department of Community Medicine, GMERS Medical College, Vadnagar, Gujarat, India
2 Department of Community Medicine, Nootan Medical College and Research Centre, Sankalchand Patel University, Visnagar, Gujarat, India
Address for correspondence: Dr. Ruchita Lunagariya, Department of Community Medicine, Sal Institute of Medical Sciences, Ahmedabad - 380 060, Gujarat, India. E-mail: ruchita_16@ymail.com
Jul-Aug 2024
09 7 2024
49 4 610616
01 2 2023
09 4 2024
Copyright: © 2024 Indian Journal of Community Medicine
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Background:

National Medical Commission (NMC) in their recent notification included Family Adoption Program (FAP) in the undergraduate curriculum to provide a learning opportunity towards community-based health care to Indian medical graduates. This study is carried out to explore and know strengths, weaknesses, opportunities, and challenges of FAP.

Materials and Methods:

FAP were used to gather data using Focus Group Discussion (FGD) and in-depth interviews of the stakeholders of the program. FGD of students was conducted. In-depth interviews of families, Sarpanch, Panchayat members, ASHA workers of the village, faculties, and Head of the Department of Community Medicine were conducted. Data analysis was done by using deductive–inductive content analysis method using computer software NVivo.

Results:

Four main categories or themes were formed: strengths, weaknesses, opportunities, and challenges. Strengths include increased understanding about Community Medicine subject, beneficence to students, and community. Weakness includes difficulties in field with respect to time and availability and implementation of programs. Opportunities include early field exposure and FAP as a platform for primary healthcare. Challenges include competencies not aligned with phasewise curriculum and difficulties in adopting five families per student.

Conclusions:

The family adoption program needs to be adopted and implemented as a part of curriculum for MBBS students as there are many strengths and opportunities, while weaknesses and challenges need to be addressed.

CBME
family adoption program
focus group discussion
in-depth interview
qualitative research
SWOC analysis
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pmcINTRODUCTION

In India, around 65.5% of population resides in rural settings (as per 2020 statistics), whereas availability of health care facilities and services is skewed toward urban setups. Hence, steps must be taken to improve healthcare access for the impoverished and rural populations as well as to provide aspiring healthcare professionals with community-based and community-oriented training.[1]

There are 662,538 villages distributed among 736 districts in India. If health care facilities to the rural poor are upgraded by even a small percentage, the country can make great strides in improving its landscape of overall health.[2] One of the major lacunae of the current Indian medical education seems to be ‘production of doctors with poor practical knowledge’. The deficiency is in terms of training in identifying disease, differentiating a serious condition requiring emergency treatment from a milder or chronic ailment, and practical training of administering intravenous fluids, drawing blood, wound dressings, and such other rudimentary skills, so that such doctors can cater to the rural health care needs efficiently. Since the year 2000, the motto of ‘health for all’ is poorly realized due to various reasons.[2] Global Consensus for Social Accountability of Medical Schools (GCSA) defines a socially accountable medical school as one that uses evaluation and accreditation to assess their performance and impact; responds to current and future health needs and challenges in society; reorients its education, research, and service priorities accordingly; and strengthens governance and partnerships with other stakeholders.[3] Family Adoption Programs (FAPs) will provide platform for training in primary health care. National Medical Commission (NMC) in their recent notification included FAP in the undergraduate curriculum.[4]

FAP aims to provide an experiential learning opportunity to Indian Medical graduates toward community-based health care and thereby enhance equity in health with objectives to direct learners toward primary healthcare, raise community awareness of health issues, serve as the community’s initial point of contact for any health-related concerns, act as a conduit between the population and relevant health care facility, and generate and analyze related data for improving health outcomes and evidence-based clinical practices. It was implemented from MBBS batch 2021–22.[1] The aim of FAP is to ensure enhanced healthcare services in rural areas. The outcomes achieved by the village and students will be documented in a database. ASHA may also be included in the program to help the students and doctors.[5]

Competency-based medical education (CBME) is an approach to prepare competent physicians for practice.[6] CBME is an approach to ensure that the medical students develop those competencies which are desired to meet the needs of patients in a community and at the same time meet international standards.[7]

The community medicine departments have played a central role in ensuring a “community outlook” to healthcare services, in contrast to the hospital-based clinical outlook of other specialties. While the focus in clinical medicine is on an individual patient, community medicine recognizes that several additional determinants have also contributed toward the development of the same condition. Integrating these various dimensions cannot be a demonstration exercise in skills. Given the growing importance of community medicine departments in the nation’s evolving public health education landscape, it is imperative to guarantee that they maintain their beneficial impact on public health initiatives nationwide.[8] The WHO defines social accountability as the duty to focus their service, research, and educational endeavors on the most important health issues facing the country, area, and community that they are mandated to serve. This is the social accountability that all medical institutions are committed to.[9]

It is the need of the hour to promote partnerships/interaction between academic institution and the health system/facilities at appropriate levels to facilitate education, service, and research through information exchange, program implementation, and exchange of students and faculty; promote practice-based teaching with intersectoral linkages among various health determinants; and teaching learning to focus on inculcation of the public health skills alongside epidemiological skills for understanding of disease dynamics for effective control, need-based health planning, and program management.[10]

The present study was conducted with an aim to assess social and behavioral issues related to public health that are not achievable with quantitative methods. The goal of qualitative research is therefore to help us understand social phenomena with the help of views and experiences of all the participants.[11] Results from this study would help to explore and know strengths, weakness, opportunities, and challenges of FAP.

Aim: SWOC analysis of FAP

Objectives:

To find out strengths, weaknesses, opportunities, and challenges of FAP among students.

To find out strengths, weaknesses, opportunities, and challenges of FAP among faculties, healthcare workers, and families/beneficiaries.

METHODOLOGY

Study settings and subjects

Based on the collective experiences of the researchers and a thorough literature review, a questions guide was created for conducting interviews and FGD. Guide questions consisted of four main themes including strengths, weaknesses, opportunities, and challenges. The applicability of the guide questions was confirmed by the research team through the pilot study.

The research team constituted of five researchers who were completely familiar with qualitative research and interview methods. The participants were chosen using the purposeful sampling method. A total of 5 FGDs were conducted with 8 participants in each group. Study participants were from first year MBBS batch who were part of FAP. Students had nine visits to their allotted families. Students who completed all the visits and filled the family proforma were included in the study. Study was conducted for a duration of 3 months.

Data collection

For each FGD, the moderator/interviewer started with introduction explaining the nature and purpose of the study. The study objectives and question guides were explained after taking written consent from the participants and ensuring anonymity and confidentiality to them. Discussion was initiated with four main themes consecutively. The participants were encouraged to talk openly about their experiences and opinions relating to programs. Probes were used to examine topics that the participants did not naturally address and to validate notions that were expressed by them. The researchers took field notes immediately and discussed these points further with them to assess their perceptions. The investigator made sure the participants understood what the other participants meant about them by reading the recorded comments back to them. Each FGD lasted 1.5–2 hours and ended when no new issues seemed to arise and data saturation was achieved.

Similarly, in-depth interviews of five families who were part of this program were conducted. Also, IDI of Sarpanch, Panchayat members, ASHA workers of the village, faculties, and Head of the Department of Community Medicine was conducted. Each interview lasted for around 1 hour.

Data analysis

Using the grounded theory approach where the data drive further analysis, data analysis was done by using deductive–inductive content analysis method. The structure of the analysis was based on previous knowledge and the purpose of the study.

In this step, while reading through the data, the researcher assigned codes to chunks of data. Notes were thoroughly read and reread for line-by-line coding to generate initial codes. A code list was prepared for the manual coding of textual data. The units of analysis were words and statements under a given coding category. This led to emergence of categories and subcategories. These were later grouped and regrouped. Finally, categories were established. Computer software NVivo was used for data analysis. It is a piece of software used to organize, analyze, and find insights in unstructured data like interviews and FGDs in qualitative research.

In the final step, different categories were linked to develop a logical explanation (or a theory) for the phenomenon being studied.

In order to increase the reliability of data, all codes and themes/categories and subthemes/subcategories were crosschecked by research team members and disagreements were resolved. To address conformability, we shared summarized interview findings with participants at the end (respondent validation) to get participants’ recognition of the findings. To improve validity, peer checking of data by members was performed to verify whether they too agreed with the observations. Team consistency checks between colleagues were also performed throughout the coding process. Ethical clearance was taken from the Institutional Ethical Committee (IEC).

RESULTS

Four main categories or themes were formed: (1) strengths, (2) weaknesses, (3) opportunities, and (4) challenges. Each category was further subdivided into various subcategories.

Strengths

Increased understanding about community medicine subject

Faculty members of Community Medicine department agreed that FAP will help students to better understand the subject. Almost all students agreed that this will help develop their interest in the subject.

Beneficence to students

A student expressed “I am able to interact with families as a Doctor in my first year itself”. Students are benefitted by developing better communication skills, confidence buildup, understanding local languages, and rapport building with the community. The majority of the students agreed that FAP helped them to develop good listening skills, counseling skills, leadership, and motivation skills. This ultimately leads them to achieve goals of Indian medical graduates. Few students agreed that it will also help to improve peer communication. A faculty member expressed that competent future doctors will be produced who will be able to manage rural health as well. Another faculty member expressed that students will learn health in all dimensions. It builds holistic approach naturally.

Beneficence to community

Increased health literacy is seen among the beneficiaries. Two students revealed, “They disclosed to us the minor illnesses they had been ignoring otherwise. There is increased awareness about hygiene, sanitation, food covering, handwashing, waste disposal, water drainage, mosquito breeding prevention, nutrition, vaccination etc.” Another student conveyed, “Many people had never seen the blood pressure instrument before and many are not aware of their blood group. So, they will become self-aware about their health parameters”. People are also benefitted in diagnostic medical camps arranged at the villages where they get specialist care in the village itself along with referral, hospitalization, and treatment at subsidised rates. Few students agreed that this program will improve the rural health by improving the health status of the community. As each family is allotted a student, it will help to spread the health awareness, reduce ignorance of health issues, monitor community behavior change, and increase trust on doctors. ASHA of the village also revealed, “People are getting more information about health, health schemes and their benefits etc., One doctor per family is good. At least once a month visit by these doctors will be better. Students’ support will benefit my work in giving health education also.” A family member under FAP revealed, “We are happy with the visit by these doctors. They do our check-up and give proper advice and refer to higher hospitals.”

Enjoyment

Students accepted that they enjoyed this program and it greatly helps them to reduce the stress and pressure of studies and helps them to adapt to the new environment. Also many students agreed that it helps them in learning the subject better than theory lectures.

Practical knowledge enrichment

Students get to experience the real world in the community. They become well aware of the local diseases, social determinants, and availability of health facilities. They also get to experience differences between rural and urban health.

Research

As per the views of faculties, students are learning to analyze the data collected from their families which can be used to improve health outcomes. Under the mentorship of faculties, they will get to learn and do research.

Weaknesses

Difficulties in field with respect to time and availability

As revealed by a student, “When we travel to see family, they are not available at home”. Another student revealed, “Children cannot be met at that time since they are at school”. Another one expressed “Not all members are available at one time”. Also few students believed that time duration for visit is less.

Response from people

Students during their visit to the family observe, take history, and ask questions regarding health and its determinants. A student expressed “Families are not responding as they are not aware about health”. Another expressed “Family members give wrong information about addiction to tobacco and alcohol”. Two students agreed saying, “Females feel shy while talking about menses, pregnancy and contraception”.

Communication with local people

Some students agreed on experiencing difficulties while communicating to local people due to different regional dialect. Also a student from outstate told of facing language barrier saying, “I have to take a friend’s help every time”.

Expectations of people

Many students experienced different expectations of people in fields like asking for free medicines, free tests, and some kind of incentives.

Opportunities

Early field exposure

Faculties and many students agreed that FAP gives field exposure to the students in the first year itself. It gives them opportunity to interact with the community and get to know their customs, culture, language, traditions, habits, health seeking behavior etc.

Doctor–Patient relationship

A student accepted, “I am learning how to talk to patients of different age groups in their language to make the patient feel comfortable.” Another one said to have increased confidence to talk to patients, history taking, and to perform physical examination and some clinical procedures like measuring blood pressure. Faculties agreed that students will develop traits like empathy, politeness, rapport building, and a sense of ownership for the healthcare of patient.

AETCOM module teaching

A student conveyed, “We feel responsible. We should not treat them wrongly.” Another one revealed, “We learn about how our behaviour with patient should be. We should be humble, soft spoken, understanding.”

FAP as a platform for Primary healthcare

Faculties of Community Medicine agreed that this program will better help to deliver primary healthcare as well as secondary and tertiary healthcare by referral. People are getting aware about the health system and referral points. This also orients students toward Primary Healthcare.

Promote case-based learning

Many students agreed that, “FAP enhances active learning and helps to retain information by doing things ourselves. We can recall everything that we have experienced during exams. Also we will have confidence while practicing.” They agreed to feel motivated to read the subject. Faculties believes that FAP will help to reduce book-oriented and exam-oriented approaches. Faculties accepted that there will be better scopes for research and publication.

Orientation about determinants of health

Students expressed, “We get to know their social problems and we can help them like motivating girls for higher education.” Another said, “They share their emotional and personal feelings with us which they can’t share even with their family members “. A faculty member expressed, “Students gained knowledge of environmental aspects, vector-borne diseases, sociodemographics, etc.”

Challenges

Competencies not aligned with phasewise curriculum

As revealed by a faculty member, “It is challenging for both students and faculties as competencies in FAP are not aligned with phase wise curriculum”. A student during FGD revealed,”We can only make gross diagnosis like which system it belongs to, we can’t make pinpoint or final diagnosis based on symptoms in field.” This shows that students are unable to make clinical correlations during first year while it may be expected by the family members.

Difficulties in adopting five families per student

As proposed by NMC, it is required by each student to adopt five families during their tenure, but it was expressed by a student, “I think we can manage maximum three families properly,” while another student revealed, “We won’t be able to justify five families”. Most of the students felt that they will not be able to adopt five families because of time constraints. Also, faculties during interview expressed that students will find it difficult to adopt and monitor health of five families.

Implementation of programme

Faculty members agreed of facing difficulties in logistic allocation like weighing scale, BP instruments, and transportation. It was found to be difficult to arrange the required logistics as well as bus for all 150 students at a time. A faculty member revealed, “Implementation of program was a challenging task for faculties and orienting students about competencies was not easy as it was new for first year students.”

Resistance and refusal

Most of the students did not experience resistance or refusal, but one student revealed, “My family members refused to cooperate,” while another student revealed, “My family members were resistant to take healthcare even after my advice due to economic problem”. Table 1 shows the SWOC analysis findings of In Depth Interview of Key Persons.

Table 1: Findings of In Depth Interview (IDI) of Key Persons

Key Persons	Strengths	Weaknesses	Opportunities	Challenges	
Sarpanch and Panchayat Members	Better Health services	Families not available	Medical camps in village	More expectations by families	
Families	Doctor at doorstep	No medicines given	Provision of Health education	Time of visit to village	
ASHA	Getting helping hand	Families not always available	Counselling services	Overburdened with other responsibilities	
Faculties	-Better learning opportunities for students	Faculty shortage	-Improved Communication skills	-Logistics, Transport	
			-Case based learning	-Achieving Final outcome at the end of programme	
	-Community Health Services		-Early Field Exposure		
	-Research				

DISCUSSION

The FAP is expected to develop the core professional competency of communication skills, empathy and ability to deliver healthcare to the rural population, understanding their customs and culture etc., The aim of imparting education to the students is to make them team leaders for health care and primary consultants and learn the basic skills like arriving at a diagnosis of problems. Their hands-on field training from the start will improve their skills as doctors. Additionally, students might comprehend the disease profile in a rural context that can differ from the secondary or tertiary care environment seen at medical colleges. In addition, they would understand local beliefs and faith in various methods of disease management other than allopathy. It is expected this will widen their vision of holistic health care and management of common ailments encountered in these settings by a family physician. Faculty will be able to play as role models for the students by active involvement on field and even establish as consultants at the rural level. All these are in line with our findings in the study.[2]

According to several studies, there are several benefits of learning in the community including developing leadership skills, learning how to diagnose and treat health issues, understanding rural communities’ customs and cultural beliefs, developing empathy and being compassionate, and gaining basic medical knowledge and skills that will eventually lead to family medicine training.[4]

Participatory community-based health programs (CBHPs) have been acknowledged as an essential tool in health promotion. Effectiveness studies are providing more and more evidence that community and other sector involvement may enhance quality and safety, promote patient involvement in treatment decisions, and improve health outcomes.[11]

Diab et al. in a qualitative study in South Africa had cited the short-term benefits that the community achieved from community-based education (CBE) as improved service delivery, reduction of hospital referrals, community-oriented primary health care, and improved communication with patients, and long-term benefits included improved teaching through a relationship with an academic institution and students’ participation in community upliftment projects, thereby acting as agents of change in these communities.[12]

Experience from Australia and Canada showed that through Longitudinal Integrated Clerkships (LICs), year-long community-based placements, students gain strong communication skills and excellent clinical reasoning and management skills, which they described as ‘Meaningful personal learning experiences’.

But implementation of this FAP poses a challenge in India. This requires each medical college at the RHTC to have a strong infrastructure, including adequate funding, human resources, and transportation support in addition to comfortable accommodation facilities. ASHA workers working at grassroot levels are already overburdened with their routine activities which will create a problem to engage them in FAP activities. Department of Community Medicine is having faculties as per the NMC norms, but they are engaged in teaching and training activities throughout the year from 1st to 3rd Professional MBBS with multiple batches, along with implementation of national programs and participation in administrative activities at college levels. These challenges are also found in our study.

Within the 1-year span of 1st Professional, the students have to pay 9 visits (27 hours duration) to complete the competencies, for which they have to know the survey methodology, PRA techniques, communication skill, history taking, clinical examination, and management of illnesses which seemed to be impossible without any clinical exposure and in an overburdened situation to grasp the 1st Professional subjects. A similar challenge of competency is found in our study.[4]

According to a critical analysis of research conducted in North America, students’ exposure to rural life shaped their interest in primary care specializations and rural practice. In general, students expressed high levels of satisfaction.[13]

Garg BS in a study conducted in 2016 on impementation of Community Based Medical Education at MGIMS, Sevagram gave description of benefits of community besed teachings. Medical undergraduates could understand the subject matter and learn skill-based topics like IMNCI, PHC, cold chain system, immunization and health education, dietary survey, and survey methods through field-based camp approaches.

Students who participated in community-based teaching, according to Kristina et al.,[14] were able to value what they had learned. Al-Dabbagh et al.[15] found task-based community-oriented teaching models useful for teaching Family Medicine in Iraqui Medical schools. Connor et al.[16] has recommended integration of social sciences within medical domain. According to Murrey et al.,[17] adoption of community orientation in medical education has potential benefits for the students, medical schools, and community.

Undergraduate students are given the chance to engage in community-based research on priority health concerns in order to develop their research aptitude and interest in these areas (Essential National Health Research). Through these surveys, they learn about data collection, entry, analysis, and report writing.[3]

The strength of the study is that the results of the current study will prove to be of great help for other medical colleges with respect to avoidance, being prepared and preplanning for the challenges which may be encountered, and filling the gaps and weaknesses in the program while implementing in their settings. Opportunities can be utilized to strengthen the program further.

Further, this is the first study of its kind in which qualitative research methodology has been adopted to explore the perspectives of students as well as faculties and other stakeholders.

Many important key aspects of FAP with respect to strengths, weaknesses, opportunities, and challenges have been identified. These can be used by the policy makers to rectify the shortcomings.

The limitation is that participants from a single batch from a single medical college were involved to get detailed information. Hence, present study illustrates the opinion of the people in FGDs and individual interviews and should for methodological reasons (qualitative approach) not be generalized to other conditions. Triangulation with other groups was not done to confirm the findings.

CONCLUSION

So, the present study revealed various perspectives of all the stakeholders. We found many strengths of FAP like it is beneficial to students as well as community. It increases understanding of Community Medicine subject and also promotes research inclination among students. As found in our analysis, FAP can be used as an opportunity to provide early field exposure, case-based learning, improved doctor–patient relationship etc. Present study also found weaknesses with respect to difficulties in field, response and expectations of people and challenges regarding implementation of program. These weaknesses and challenges identified needs to be assessed and acted upon for further improving FAP.

With this study, we conclude that FAP provides an experiential learning opportunity to Indian medical graduates toward community-based health. At the end of the program, students may be envisioned to become leaders for the community. The NMC vision can be achieved by FAP.

Thus FAP through village outreach needs to be adopted as a part of curriculum for MBBS students. This will have several advantages of making MBBS students as ‘complete doctors’ with humane approach and confidence to be leaders in sociomedical fronts. The neglected rural population will be enriched and the results for the country will be seen in next few years. FAP will help in building all three domains of learning effectively. Present research identified strengths, weaknesses, opportunities and challenges in implementation of FAP and contributed in generation of hypothesis for future intervention research. This study will help other colleges yet to implement the program. SWOC analysis will also help in further improvements and amendments of the program.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.
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